Small but Mighty: Challenges, Triumphs, and Community at Cascade Medical Center

Critical Access Hospitals, tasked with providing vital hospital services to their rural populations, face unique challenges while serving their sprawling communities within the confines of budget, space, and oftentimes aging facilities. Strategic healthcare design can be a secret weapon in enhancing patient outcomes and staff wellbeing within these limitations.

Hosted by: 
Matt Gerstner - BWBR Podcast Host and Producer

Guests:
Brad Krump, AIA - BWBR Principal, Director
Tom Reinhardt - Cascade Medical Center CEO 

Music provided by Artlist.io
Siberian Summer by Sunny Fruit
DuDa by Ian Post

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Transcript

Matthew Gerstner  

This is Side of Design from BWBR, a podcast discussing all aspects of design with knowledge leaders from every part of the industry.

Matthew Gerstner  

Hello and welcome to Side of Design from BWBR. I'm your host Matt Gerstner. On this episode, we'll be digging deeper into some of the unique challenges and opportunities specifically faced by small critical access hospitals, who are tasked with providing vital hospital services to their rural populations within the space, staffing and budget confines that come along with those circumstances. Today, we're fortunate to be joined by Tom Reinhardt, CEO of Cascade Medical Center in Idaho, as well as Brad Krump, BWBR Healthcare Principal. They're here to talk about the joys and realities of serving a small community, and how design can support efficiencies and expanded services for this important work. Tom, Brad, thank you both for being here today.

Tom Reinhardt  

Thanks for having me.

Brad Krump  

Thank you, Matt. Tom, thank you so much for wanting to come on to our podcast and share a little bit about small critical access hospitals. I'll just put a plug in that small critical access hospitals, we view those as eight patient rooms or less, and it's really unique. They're scattered all over the country, but yet, they're fabulous places to help on the design process.

Matthew Gerstner  

Brad, thank you so much for the definition of what a critical access hospital is. So we'll just kind of get right into this, if you don't mind. Tom, can you tell us a little bit about Cascade Medical Center, and what makes it special?

Tom Reinhardt  

Sure. Well, a cascade Medical Center, first of all, is in cascade, Idaho. This is a small rural mountain community in the middle of the state. And like a lot of rural communities, we have a critical access hospital, Cascade Medical Center is a critical access hospital. We also have a rural health clinic and a busy physical therapy practice. So that's the nuts and bolts of our organization. The community of Cascade is 1000 people. And the service area that we serve is larger than some states. It's a big geographic area with only with about 4000 people, certainly more cows than people who live here. The Medical Center is really critical to the community, because we are the closest access for critical health care services. In fact, there's a community we serve called Yellow Pine that is two hours away in good weather by car, and we're the closest medical facility to them for even for a doctor's office, let alone for a hospital. So we're really vital to the community for health care. But also, you know, as an employer of 70 individuals, we provide an important economic base to the community.

Matthew Gerstner  

I can see how that would be. I mean, you mentioned that it's a large geographic area that you're covering. And so I can see how that would be extremely important to the people that do choose to live out in that area. If you have to travel at the closest two hours to get medical care, that can be kind of a daunting experience, I'm sure in some cases, right?

Tom Reinhardt  

Yeah, definitely.

Brad Krump  

Tom, let me let me ask you a question just for a second. As a small rural community, not far from a large metropolitan area, Boise, being in cascade and understanding some of the recreational value and the number of people that that come to your area to recreate. You mentioned, there's 4000 people in your service area. But what kind of influx of visitors and guests do you get both in the winter and in the summer months that that really expand your population beyond those 4000?

Tom Reinhardt  

That's a great question, Brad. So there are times when our community swells to well over 10,000 people, and often multiples of that, during especially during the summer months, when people come up here to escape the heat from Boise as well as to recreate in the mountains and even in the winter because we have great ski resorts here. People from Boise come up and as Boise grows then the number of people come up here to recreate also grows. Cascade Medical Center has been here for over 50 years. And in that time, we've really evolved from a, primarily a natural resources extraction, economy, logging and agriculture and mining in wood mills into primarily a tourism destination where a lot of our local economy is dependent upon people traveling here and retiring here. In order to keep the community's economy going, making health care as an economic sector even more important, because in health care jobs tend to pay pretty well. And then with the growing number of retirees here, of course, as we get older, we consume more and more health care services. And people who, who are looking at geez, where do I want to retire, I don't want to retire in a big city, they often one of the big criteria is for them is I need to live in a community that has health care, and ideally has a hospital. And so we do find people retiring here and selecting Cascade, specifically because we have a hospital.

Brad Krump  

And Tom, Can you also talk a little bit about the influx, how many normal ed a day maybe 10 to 12, for you making that number up. But Fourth of July weekend, you may see three to four times based on our experience, what do you see in Cascade?

Tom Reinhardt  

Yeah, you know, our average year round is only four to five ER visits. And our slow times are the fall and the spring. But in the in July, we would average 9 to 10 ER visits in a 24 hour period. Now a lot of people say, Well, that didn't like much, and certainly to a big hospital and trauma center, like those Boise, that's a small number. But we're staffed accordingly. And we are the frontline for traumas for heart attacks, strokes, all the time sensitive emergencies, and EMS brings them here, people drive here. And then we do you know, the initial assessment and triage, and oftentimes we're able to take care of them and release them to home. More than 95% of our patients are able to be discharged from ER to home. But those, you know, really sick patients, those who have really bad traumas, they're transferred. And so we have a pretty busy lifeflight pad outside our parking lot.

Matthew Gerstner  

I can imagine for anything that gets gets beyond what your what your, your smaller staff is capable of handling, that can be a very critical thing for that area. 

Tom Reinhardt  

Yeah. 

Matthew Gerstner  

So what do you see as some of the unique challenges that small critical access hospitals are facing?

Tom Reinhardt  

Well, for us, I would say, there's really two critical issues that that we struggle with both short term and long term. One, of course, is staffing, right? I think every business, plumbing, restaurants, health care, we all struggle with finding qualified licensed staff, and even beyond that those who are really, you know, engaged in engaging, and then retention of staff. So you know, you got to find the right people in you got to keep them. One of the challenges that we have in a resort community retirement community is that it's expensive to live, the housing is super expensive, and people need to live, earn a livable wage. And so while a lot of people who work in healthcare do earn a really great salary, we also have, you know, quite a few people who work here who you know, need to survive on that $15 to $20 per hour rate. And it can be really challenging for them to find a suitable place to live and to be able to do so up here in a resort community. So staffing is a challenge. Staffing is a challenge for everyone, certainly in in healthcare, because we're a growing sector of the economy. We're continuing to add more workers. And you know, there was already a nurse shortage, there was already a shortage of RAD techs before the 21st century and certainly before COVID And all of that has been exacerbated since COVID. So that's, that's one of the two challenges of staffing. The second one is renewing our infrastructure, certainly, technology advances and it advances at an accelerating rate. And there are so many rural hospitals like ours, that were built during the Hill-Burton Act era, where now our facilities are really getting old and tired and and out of compliance in many ways that we need to build a replacement facility or make a huge renovations to to add expansions to our facility to keep up and finding the capital to support those renovations. And replacement of the facility is really difficult. The margins are thinner than ever in health care and an organization like us, we're a government hospital, if you will. We're a district hospital. We're supported by the property taxes of the people who live here. People are very tax averse, especially in areas like Idaho. And so being able to pass a bond to support the building of a new hospital is really really tough. And so that's those are the two things we struggle with staffing and renewing our facilities.

Brad Krump  

Tom, just to add on as it's helping you early in the design process, so 18 months ago, one of the interesting aspects when we programmed your building, we programmed the building to be about 32,000 square feet, when we were said and done. Compare that to today, where you're just over 12,000 square feet. Now we didn't add a lot of program to the building. You currently don't have surgery, and we look to add surgical to to your new hospital, which was about 3000 square feet. But if you compare that 12,000 to 30,000, that is just right sizing the building to be in today's standards. So just a very interesting take on on the building you're working in today. And what it would take if you were starting from scratch, and you can see the comparison between how you're working today and what it would take to work in the future. In one added note, I give you a lot of kudos because I don't know too many folks that would be able to take your CTE that you currently have added to your facility to serve the patients that you have for heart attack, stroke, etc, and be able to put it outside of your existing footprint, but to be smart enough to put it into a storage container to make it accessible and usable for the community.

Tom Reinhardt  

Yeah, you know, running a hospital in a rural area is all about flexibility, and compromise. You know, we have to find ways to make do with what we have. And a lot of the people who live here, their expectations, the outcome of healthcare are high as they should be, but they don't want or need anything fancy. So they say, but it's gets really hard to continue to deliver great medical outcomes. In a 12,000 square foot facility. There are nice homes being built near here that are over 20,000 square feet. So it's really hard to manage a hospital that is 12,000 square feet, it's been 12,000 square feet for 25 years, despite the growth that we've seen.

Matthew Gerstner  

Wow, that yeah, that that can be an issue, I'm sure. And you mentioned the ability to attract staff and retain staff. And you're talking about an aging facility, I can see that really being a double edged sword in a lot of ways.

Tom Reinhardt  

You know, our facility presents challenges in a number of ways. And Matt, you're right, including in the recruitment and retention of staff, people want to work for an A plus organization, and the appearance of your facility. And the moderness of your facility absolutely impacts your ability to staff it. You know, when when we sat down and wrapped our arms around the idea of needing to build a new hospital and engaged BWBR. To help us with that design. From our perspective, we were looking at really four key things that we wanted to accomplish. We wanted a beautiful facility, right the aesthetics of it, we can go into these one by one, but we wanted an attractive facility. Two, We wanted to make sure we had a facility that supported the healing of our work and that contributed to patient outcomes. Three, we wanted a facility that helped us recruit and retain our staff and allowed our employees to be well at work since they spend so much time here. And then fourth, and certainly not least, is just operational efficiency. We needed to make sure that we were able to meet our labor and cost goals and wanted to make sure that the facility could contribute to that map. 

Brad Krump  

Matt, design process was really well done. And of course it was interactive, as we always do. There was several things that were really important in regards to flex, flexibility and adaptability. We have one main entrance for both inpatients and outpatients. We have a centralized nurse station for ED, surgery and med surg. So we can we can flex up staff and flex down depending on the shift. We have shared treatment and pre/post rooms between ED and surgery for high census days in ED or low census days for surgery because surgery may not be five days a week in your community maybe once or twice a week as you start to grow your surgical platform. We have eight med surg rooms that can flex from patients. So a couple of rooms that have dual capacity, or dual occupancy. We were careful to right size the building. But then we also looked at an outbuilding to be able to do some of the storage of equipment and other things, again to reduce as much as possible the overall footprint of the new hospital which was a higher dollar cost. We looked from a proximity standpoint, imaging is close to the ED, lab as close to the front door and close to the clinic with backdoor access to the med surg unit. And then pharmacy is right in the middle of the heart of the hospital in the ED and med surg unit. And then the last thing we talked about is where would we grow in the future, so we weren't boxed in. So Tom could be able to expand as the community grows over time. So I'm really looking at zones to be able to allow for growth in the future and really be smart about where we place everything. So it doesn't have to be redone, which costs extra in the future.

Tom Reinhardt  

Yeah, you know, Matt, when Brad and his team came on, we had some general ideas of what we wanted to accomplish, but they really helped us sort of dial in and think through the workflow, not just aesthetics, but the workflow of working in a hospital and how the design and the location of departments and workstations could contribute to our efficiency. And that was awesome. So in addition to the things that Brad just mentioned, the ability for us to flex staff, between tasks inbetween departments is absolutely critical. And not just like, on one day, Tom is going to be a nurse in med surg, and on the next day, he's going to go to a different floor and be a nurse in the ER, no. When you're small like this. Tom has to be able to be a nurse in the ER, from 2:00 to 2:15. And then I have to be a nurse from 2:15 to 2:30 in med surg. Well, how can I do that? Well, you know, Brad, and his team sort of helped us figure out, okay, let's place the nurse's station in this location. So that you know, to the right is the ER and good visibility to patient rooms on the left is med surg, and then over in the back behind, you've got maybe pacu, so that one nurse can be able to be dual and triple deployed to be able to support that we're not big enough to have an ER staff and an inpatient staff and recovery staff. Everybody wears multiple hats, oftentimes in the same hour, and the design supported our ability to do that.

Matthew Gerstner  

That really sounds like there was the right amount of time spent on spatial planning for this particular project. Because it certainly sounds like, you both mentioned the word efficiencies, there are specific efficiencies built into this plan. And it sounds like they  might not have existed previously.

Tom Reinhardt  

But yeah, I mean, it just over time, you sort of you evolve and healthcare changes. And even since COVID, like not, not just from before COVID. But just even in the the one year since we've had, I mean, not the COVID has gone right. But even in the year, since COVID, has been a peak problem. We have experienced incredible changes in healthcare, especially in the staffing of healthcare, and labor costs have gone way up. That's true for everybody in every industry, in healthcare, even more so as nursing and the techs are, you know, really commanding higher wages, and they're vital to our work and, and they deserve to be well paid. So being able to efficiently use that precious resource is really critical. And there's been new developments like even even since then, virtual nursing is a real thing, right? So the ability for a nurse in the nurse's station to use their screens and be able to monitor patients, not just the vital signs of patients, but actually be able to see patients in different rooms. And now somebody in South Bend, Indiana, a nurse in South Bend, Indiana, can be looking at the patients in our facility, see something, notify our nurses so that we can be boots on the ground. And all of those innovations certainly make their way into the design process. And Brad, you could probably speak more to that with some of the things you've done with other clients.

Brad Krump  

There's a lot of innovation going on and a lot of things that are happening very quickly, certainly with the lack of staff in certain communities, that idea of working with a remote monitoring system. It has been nice for additional clients that we work with. Tom I'd also mentioned that you've created quite the culture, one of the things in visiting a couple of times during early design was this concept of, of kind of eating together and having communal space. Curious if you want to chat a little bit more about or share a little bit more about this culture you've created to help with recruitment and retention of staff.

Tom Reinhardt  

So about five years ago, our turnover rate was 40% per year, and it's just hard to be able to gain any traction on anything else when you're constantly churning staff. You can't make gains in quality, you can't make gains on culture. And you're spending so much money rehiring retraining, using contract labor. I mean, it's just a downward spiral. And then, but we were able to turn that around, thanks to really the help of some great providers and leadership that we have here. And of course, the employees, nobody wants to work for a crappy organization, everybody wants to be a winner. So you know, everybody was on board with that. So over time, you know, we cut that 40, down to 30, down to 20. And last year, we had 11% turnover. And a lot of that has to do with certainly taking time with the staff being transparent about everything that you're doing, communicate, communicate, communicate, engage the staff, and how we can improve things together, all of that really is vital. And space is is a part of that whole thing. I mean, it's not just one thing, you have to do 100 things right, in order to build a good culture. And so you know, one of the things that we do is we all eat together, I would like to say that that was intentional, but the fact is, we only have one room, it's the Cafe-gym-atorium. And we do everything there and there's no other place to eat. So that's where you're going to eat, you know, kind of nice thing. It helps build community within staff. But as we designed our new place, BWBR helped us think through other aspects and how we could accomplish that what are the offstage areas that staff can actually sort of, you know, escape to and get a break from that constant pressure of patient care? How can they sort of connect with each other? And where can they take a breath and relax and do the things that they need to do to be real humans that we want to keep and sustain for the long term?

Brad Krump  

Yeah, Tom, I mean, you're right, we did specifically design that kitchen area to be a communal space. Adjacent to that we have a staff area, staff break area. So if people want to get away to a more quiet space, that's possible. In the clinic planning, we have an open area for work staff, so they can be more collaborative in team building. But next to that, we have two quiet rooms for people that need some time and some space, away from all the buzz and activity, whether that's to have five minutes to make a phone call, either for worker or for themselves, or if it comes down to, I just got done with a really rough visit and I need five minutes to pull myself together. In this day and age that happens in you need to be able to provide space forth, they have to be able to get themselves together to get back to their next patient and really portray a professional image to your community.

Matthew Gerstner  

So you're both talking about the staff, and giving them spaces to spend time together to decompress, if you will, inbetween when they have their breaks that they need that kind of thing. So we're really starting to get into a little bit of a conversation on behavioral and mental health in some ways. So when we're talking about behavioral mental health and the well being of your staff and the well being of patients, how does behavioral health factor in to critical access hospitals here, especially in your community?

Tom Reinhardt  

It's fully part of the fabric. It's woven in with everything that we do, Matt, you're exactly right on. If you have a staff that is is healthy, and well, they're going to be more effective and taking care of our patients. And our you know, our patients are coming to us in on the hospital side, they're coming to us on their worst day, you know, our best day is taking care of people on their worst day. My job isn't taking care of patients. My job is to take care of our staff. And that's what I get up every morning, excited to do so that they can then take care of our patients, which is the reason that we're here for the community. So those employee spaces that Brad spoke about, that's part of how we can take care of our staff and help them be well. Certainly there's a lot of design elements involved in keeping our community and our patients mentally well, whether it's an acute situation, a crisis situation in the ER where we need a safe from. And we need to be able to keep patients and staff safe from patients who may be having a crisis event to on the outpatient side, having good mental health counseling rooms that are quiet and a place for us to be able to effectively provide mental health services

Brad Krump  

And Matt, just to add on to Tom, as part of our design process. Those outpatient behavioral spaces are part of the clinic, but they were strategically located to be towards the back of the clinic where it's quieter, and also to the outside, on an exterior walls. So they add views to, in the access to natural light. And again, as a way to help calm that patient, and hopefully, make sure that that patient does not escalate while the visit or encounters going on. And then in the ED, of course, having a safe room as part of the ED treatment room, whatever should be a safe room, once you have one of those patients, how do you either de escalate that patient so they can go back home, or be able to hold that patient which can be for an extended period of time, which ties up a room for you. But the ability to transfer that patient to get the right level of care needed, which seems to be an issue for many of our clients that that they are staying in your community longer than what the desire may be, maybe you can add to that.

Tom Reinhardt  

Mental health is is a challenge and a crisis across the country, it's especially an issue in rural areas. And there are often times when we want to get a patient to the right place of care for their situation. But all of the available beds are full, or there's other circumstances that prevent the patient from being accepted right now. And we're not experts in mental health care. But as you mentioned, Brad, we often are in the situation for taking care of patients for anywhere from a few hours to several days. And just until we can get a mental health facility to accept the patient. So it challenges our staff and the facility needs to be able to sort of provide that infrastructure to make it possible.

Matthew Gerstner  

So that's just fantastic. It sounds like that was something that was certainly considered in the design process. Because I know with critical access hospitals, it can be challenging to find the dollars and find the funding to provide those types of facilities in the in a rural environment. So that's kudos to thinking about that in advance and bringing that into the design.

Brad Krump  

Tom, Do you want to do you want to just talk a little bit about I believe you just recently got a grant for your existing facility to help with creating a safe room within your ED?

Tom Reinhardt  

We did. We we got a couple of grants that totaled $35,000, which was almost exactly what we needed in order to convert a regular inpatient room into a safe room. And I'm glad we did it because CMS just kind of came out with some increased guidance about how facility surveyors need to make sure that a hospital has appropriate facilities in order to take care of patients who are at risk of harming themselves or others. So it's it's, the timing was great to be able to receive that grant and do that work. So you know, certainly the things like a ligature free environment so people can hang themselves on light fixtures or, or doorknobs. Certainly avoiding anything sharp or breakable. But to do that in an environment, that's not a rubber room, right? I mean, you, you want to treat the patient with honor and dignity. You want to be able to bring natural light into the space. So you'd still want a window. You can't have a window that's going to break but you still need a window. You want to be able to allow the the patient to use the toilet, but still have some privacy. But you can't close the door, right? The all of these things are tricky in the design of a safe room. We call it a safe-ish room because you can't, there's no way to be perfect.

Tom Reinhardt  

Can you talk, Brad, Tom, both of you. Can you talk a little bit about the vision for a new Cascade Medical Center space and what you hoped it could do for the overall community a little bit.

Tom Reinhardt  

I'll start Brad in that you know, in terms of the overall community, Matt, we wanted to be a point of pride for our community. We wanted to have a facility, as long as you're spending the money and you're going to build some, let's build some great, let's build something that's going to look fantastic. And not just to reflect upon the brand of Cascade Medical Center, but that you know, which is important. We want people to have confidence and pride in, you know, a good looking facility gives gives you that if you're a patient, or a family member, but it's also important to have it be a source of pride for the community. And that, you know, a nice hospital can really speak well to the community. People who are visiting people who are just passing through, who are thinking about moving there. They see a nice look in hospital think, yeah, this this community's got it going on this community knows what it's doing. It's prioritizing its people. It's prioritizing its responsibilities. And healthcare is important to every single person here. And it speaks well, to have a good looking hospital.

Brad Krump  

Yeah, absolutely, Tom. And, you know, what we do as architects, at BWBR is really focus on sharing and creating an atmosphere, an exterior, a vision that our client is telling us they desire. They don't know exactly how to put it into words. But in our design process, we share ideas and get feedback on those ideas in a quick way, to in real time kind of figure out what is the desired look for Tom in Cascade Idaho. And what we were looking for is something and these are the community's words, a facility that embodies a joyful and healing place for patients, visitors and staff. Now, that doesn't tell you what the exterior of the building should look like. But in being in a remote location in Idaho that has mountains not that far away, it has lakes and streams relatively close. Tom did a great job, he bought property right on the main north south thoroughfare going right through his comunity. So he has a fabulous location and presence for the future location of the facility. And what we looked at is, it was too expensive to do a hip roof to make it look like a residence. But what we did is looked at things that could make it look similar to maybe a chalet. So we had some sloped roof components that portrayed this look of like it would fit within this remote rural community in central Idaho. And then we appropriately used a little bit of wood looking material, and combined that with some stone accents. So not a lot of stone, which is which is a more more costly material, but putting it at the right place, putting it at the front door. But in at the entrance to the emergency department where people would know, along with signage how to show up to a building and present themselves. And being very careful about the look and feel, but using the vision that was shared with us and then providing options for them to review and say yeah, that looks like Cascade or not really. But together collaboratively, we came up with creating the right look and feel for the community.

Tom Reinhardt  

Yeah. And Brad, I remind me the name of your one of your senior leaders who came and facilitated the session with the community. 

Brad Krump  

Was it Scott or Steve, or both? 

Tom Reinhardt  

I want to say it was Scott, Scott from BWBR came in and ahead of time had given us instructions for how to invite people to a brainstorming session or reflection session, have it in a big place where they can, we can get enough people that can accommodate a good cross section of the community. Because we're not building Tom's hospital, we're building their hospital, this is their hospital, and we want them to have input into the design. And people don't always know what they want, right. And they need to sort of reflect and react to different options. And so Scott came in and he facilitated a great session gave people a lot of opportunity to give input, you know, we want this kind of thing and that kind of thing. And then he put up a number of different design options, you know, different materials, different roof looks, and allowed people to respond to that. And the outcome of that process was a really strong buy in for what this future facility could look like. And then sort of in the ensuing iteration of design took into considerations, things that I never would have thought about. Like, as we build a shed roofs, we had a couple of shed roofs incorporated into the design, so that you could start the efficiency of a flat roof building. But from the road, from the parking lot, it looks like there's angled roofs, which is so you kind of get the best of both worlds. And then how should that shed roof be angled? Should they be angled east to west or west to east? And I don't know. But they were like, well, you know, given that we kind of live at the 45th parallel and how the sun is coming from the south and where the mountain is, you know, you're going to be able to bring in the best light if they're angled this way. But keep in mind, you know, it gets hot in the afternoon in the summer. And then well, what about in the winter, you know, that your snow is going to blow in from this direction, pile up and cover the windows. I mean, I don't think about these things. But the BWBR team members, you know, they kind of were thinking all that stuff through for us.

Brad Krump  

Yeah Matt, one of the one of the features that Tom is talking about is we have borrowed light on the roof, or above the roof in our public space. And it goes from the front of the building at the main entrance, through the back of the building, what would normally be kind of a darker space, the ability to be daylit public space all the way to the lab area, and really create this spine in the middle of the building. So that was this feature. And there was a lot of discussion about the appropriate nature of it. We forget coming as a midwestern firm, that it snows a lot in cascade. So we had to think a lot about, okay, what are we going to do when we get four feet of snow? 

Matthew Gerstner  

Right? 

Brad Krump  

How are you going to have roof access? What is that going to look like? We even talked about parking a snowblower on the roof. So if needed, they could get to the air handling units in the winter, because otherwise, it'd be incredibly difficult to get to them. We also talked about the vestibule on the rooftop unit. So you could work inside if you needed to change a filter in the winter, but you still need access and to be able to get to the handling unit. So even though it's relatively close, you still need a path to it once you get onto the roof, knowing that, you know, we don't have endless resources available to do something with an enclosed penthouse that we may do with a larger facility.

Tom Reinhardt  

Yeah, I'm glad you mentioned the lab too Brad because so often labs are in the basements of hospitals, and I feel bad for those poor lab employees, you know, and they just want a little bit of light. And so Brad and his team was able to figure out, you know, how do we get light even into those backroom areas where we, you know, and it's not for the patients, this gets back to employee wellness, this gets back to employee retention. You know, we're competing for lab employees with every other hospital in the area. You know, we want to give our lab employees the opportunity to work in a healing environment, because they're here 8, 10, 12 hour shifts. They matter. They matter to us.

Matthew Gerstner  

I think people underestimate how important daylight is. Really. I think they really underestimate how important daylight is and it's a great point that you make when you're talking about. It's not just for the patients that come in. It's for the employees too. And I sure that does help with employee mindset, and mood. And if they're doing well, and they're feeling good, that just translates right back over the patient's side.

Tom Reinhardt  

99% of our patients are here for an hour and a half or less. Honestly, the daylight isn't for them. The day light is for our staff. The other thing that the team incorporated into the design was this anticipation of growth path for the hospital. Because, you know, this is going to be a hospital for the next 50 or 100 years. We're going to grow. And so Brad's team put administration, like it was kind of in the front of the building between the hospital and the ambulatory clinic side. And the thinking is that at some point in time, that will be prime space in the building for expansion of either surgery or radiology or the ER or clinic. Not sure exactly what but that will be ideal expansions on and when that need happens then administration. I mean, honestly, we're the lowest priority, we can go, we can go to an outbuilding we can go anywhere. But in the beginning, let's put us here, so that we can, you know, be an integral part of the hospital, and something else will go there later.

Matthew Gerstner  

I've heard this a few times throughout our conversation, but the thought that has gone into it, it might be the wrong words to use. But future proofing, in some ways, the thought that is going into future planning, planning for things that you may not even know is coming down the road with the advances in technology and medicine. You know, 50 years down the road, things may look significantly different. So it really does, Brad, if you could speak to this a little bit. I hear the talk about out buildings, I hear the talk of, you know, expansion. What kind of things were planned for here?

Brad Krump  

Oh, Matt, it's a loaded question. Some of it is just natural tendency is based on experience. So some of it's never really communicated. And other things are, for example, external growth zones, like the ability to add additional med surg beds in the future based on community need, we have that located strategically in the back corner of the building, with the ability to extrude it to add additional future beds without much work or effort, if you just add on to the existing exterior wall and extrude the number of beds as you need to for the community. Or, for example, for rehab and clinic, the ability to expand that in a different direction where we have green zone. So again, relatively easy, we could add a number of exam rooms or handle or a number of additional rehab services, as the community needs it. Tom's already mentioned about soft zones within the building, strategically placing components that don't necessarily need to be there. But they're next to a larger component that's more fixed, like radiology, as Tom mentioned, I think it's natural to say, Tom currently in his planning has a CT an X-ray room, an ultrasound and a multipurpose room. Well, that's pretty small in regards to radiology, and radiology is one of those things that continues to get more and more dependence for health care. So whether it's an MRI in the future, or an additional large wonder of technology that we're not aware of, is really critical to allow for that growth zone. So not knowing what it is today. Because I don't know what that's going to be. I'm not that smart. But I do know that things do change and adapt over time. So the ability for that to happen, is really critical. 

Matthew Gerstner  

That's fantastic. Tom, is there anything else that you wanted to cover today that maybe I haven't asked her Brad hasn't brought up? ,

Tom Reinhardt  

Well you know, it just as we were talking about winter around here, one of the things that BWBR really brought to the table is experience in working in various climates, including cold weather climates. And so they were pretty thoughtful in in the, in the external part of the facility. So how do patients get to the parking lot? Once they park? How do they walk into the building? What do they encounter along that path? And knowing how harsh winter and salt is on concrete and other materials, integrated under sidewalk heating, so that so that the walkways could remain clear, without requiring staff to constantly be going out and shoveling which by the way, we all due every day, multiple times a day in the winter, myself included, nurses were all out there shoveling right all the time. We can't continue to use our staff to do that when they're needed inside taking care of patients and it destroys the concrete. So the design team was really thoughtful about how do we deal with snow? Where are snow storage areas on site? And when they, when those piles melt? What's going to happen to that water and where's it going to go? I mean, we talked about the building design in the rooms, but it's outside of the facility as well that has been so, is so critical for us to think about.

Matthew Gerstner  

It does sound like there were a lot of unique environmental challenges for this particular project.

Brad Krump  

Tom, is there anything about messaging to your community? Like why to vote yes, in the future. Anything like, get the word out, get the message out. How critical you know, CMC is to the future of your community that you want to share?

Tom Reinhardt  

The community has voted against a bond twice now, but it's not that they're not supportive of the hospital they are. And they do see how important the hospital is to their daily lives, and to the ability of the community to continue to grow and be attractive to others. But hospitals are expensive. And we're in a challenging construction environment. And it just, you know, we're just going to have to work a little harder, we're going to have to sharpen our pencils, we're going to have to look for more ways to have dual use of space or triple use of space so that the same space can be used for an emergency room, but then it can also serve as a pacu. room the next day. And certainly those are design elements that BWBR is helping us think through and we're going to have to push harder on that to change it from a 32,000 square foot space, to a 25,000 square foot space to be able to afford to build the building that will be better today, it's not going to be ideal, but it'll be much better. And with those future growth zones that Brad was talking about, when the community needs to and can afford to expand it in the future, we'll know how we're going to do that.

Brad Krump  

Anything in regards to getting the word out to potential donors, anything you want to share that way to like the folks that own the 20,000 square foot house. Like because they have deep pockets. In small communities, outreach and community support can happen in two ways it can happen via voting, those that maybe don't live there 50 weeks out of the year, but enjoy two weeks, maybe there's a message to them that you want to portray about how important healthcare is to the community and in the vitalness, and maybe you've already covered it. So it's not important to repeat.

Tom Reinhardt  

The people who live here are good, hardworking people, they some are new here, and some are fifth generation. They're typically not millionaires or billionaires. But but those people are discovering our area because it's beautiful. And I just hope that as they come to our community, and value the community that they'll see the importance of contributing to the community, by way of supporting the hospital. And I'm not stuck on the name Cascade Medical Center, it could be Gerstner Medical Center. Right? So naming rights. I'm okay with that.

Matthew Gerstner  

Naming rights are an open Alright, Gerstner Medical Center will take that into consideration. Tom and Brad, thank you both so much for your time today. This has just been a fantastic conversation. It sounds like you're doing great things out in the Cascade Mountain Range and in your community. And we really wish you all the best.

Tom Reinhardt  

I look forward to doing a follow up show when we build the facility. That'd be fun wouldn't it.

Matthew Gerstner  

I would absolutely look forward to that. That would be great. 

Tom Reinhardt  

Cool. 

Matthew Gerstner  

That'd be wonderful. It would actually be fun to get out there. And I'll bring the camera on. We could maybe even maybe even do this in person in the same room. This would be fun. 

Tom Reinhardt  

I love it. 

Matthew Gerstner  

Thank you both gentlemen. It's been wonderful talking to you. And we'll talk to you all soon. 

Tom Reinhardt  

Okay, be well. 

Matthew Gerstner  

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